Anguillas Health Reform Towards Strengthening Health Systems and

Anguilla’s Health Reform: Towards Strengthening Health Systems and Improving Health Care Provision Presented by Dr. Bonnie Richardson-Lake Permanent Secretary Health & Social Development

Outline • • • Background Establishment of the Health Authority of Anguilla (HAA) New Role for the Ministry of Health The National Health Fund Other Initiatives

Background • Most Northerly of the Leeward Islands • United Kingdom Overseas Territory • A Governor appointed by the Queen presides over an Executive Council made up of 4 Local Government Ministers, the Deputy Governor and the Attorney General • 35 Square miles • 2001 Census--11, 561 • 2006 Population Estimate— 14, 000

Economic Activity • GDP per capita-US$ 6, 718 in 2005 • 5% of GDP was spent on health care in 2005(approx 15% of total govt budget) • Tourism sector makes the largest contribution to GDP— 28% • Government Sector--18. 7% • Finance Sector--14. 4% • Less than 1% unemployment

Health Indicators 2005 • Infant mortality rate 18. 0 • No maternal deaths 2001 -2005 • Birth Rate 11. 4 per 1, 000 (2003) • Male life expectancy--76. 52 • Female life expectancy--81. 1

Top Causes of Death (2004) • Cancer • Diabetes • Heart Disease • Stroke

Health Care System • Health care system is comprised of both private and public sector • Public sector health care is delivered by the Health Authority of Anguilla • Primary Health Care is provided in five health centres throughout the three health districts

Primary Health Care Health Centres are staffed by: • Physicians • Pharmacist • Dentist • Public Health nurses • Nurse midwives • Physiotherapist • Community health aides • Clinic aides

Primary Health Care Services provided: • Maternal and Child health • Family Planning • Immunization, • Nutrition advice • Care of the elderly • Management of chronic diseases • Health education. • Pharmacy Services • Physiotherapy • Home Visiting • General Medical Care

Secondary Care Princess Alexandra Hospital is a 36 -bed facility which provides: • Emergency treatment • Surgical Care • General medical • Pediatric • Gynecological and obstetric care • Laboratory services • Radiological and Diagnostic services • Pharmacy services • Physiotherapy

Secondary Care • Long-term Care— 16 bed senior citizen’s home • A 12 bed in-patient psychiatric wing is currently under construction and should be commissioned by the end of this year • The unit will provide services to those with acute psychiatric illness

Anguilla’s Health Care Reform In 2000 the Government of Anguilla (Go. A) took the decision to place the delivery of health care services under a semi-autonomous statutory body—The Health Authority of Anguilla (HAA)

Anguilla’s Health Reform • Go. A was committed to attaining the most productive use of resources and a more timely response to the overall requirements of the health service. • One of the main objectives of the reform was to attain a greater degree of efficiency in health services and an improvement in the delivery of quality health care • Having HAA separate from the Ministry of Health (Mo. H) removed much of the bureaucracy typically associated with the general Public Service

Anguilla’s Health Reform Management responsibilities delegated to the HAA included: • Financial • Human Resource • Operational Delivery of Health Care Services

Advantages of a Decentralized Model The devolution of the health services has several advantages: • Increased speed and clarity in decision-making and implementation • Health care can best be administered within the framework that allows institutions to manage their resources (both financial and human) directly • More empowered health officials with greater responsibility for the outcome of decisions

Advantages of a Decentralized Model • Increased Sustainability • Improved Equity • Increased Quality

Preparatory Work Before the HAA could be commissioned several critical activities had to be undertaken. These include: • Establishment of a Health Authority Project Board to recommend an implementation strategy and later the establishment of a Shadow Board • Governance Structure of the HAA • Legislative Framework—a bill for the establishment of HAA was developed with the assistance of an international legal experts

Preparatory Work • Development of personnel policies and transition arrangements • Development of financial management systems • Communication Plan for staff and public • Development of a National Strategic Plan for Health and subsequent service plans • Development of service agreements and new performance measurement systems • Selecting and training of key managers and Board Members

Preparatory Work All of the activities were coordinated by regional consultant funded by DFID

HAA The HAA was commissioned in December 2003 and became operational in January 2004 under the Health Authority of Anguilla Act

Structure of HAA Minister of Health HAA Board Chief Executive Officer Director of Nursing Services Human Resource Manager Finance Manager Facilities Manager Director of Medical Services Coordinator of Health Promotion

Mo. H Minister of Health PS Health Planner Director of Quality Management/CNO National AIDS Programme Coordinator Quality Management Officer

Role of the Mo. H • After the devolution of the health services to the HAA, Mo. H maintained the following functions: • Policy direction • Strategic Planning for Health • Regulatory/licensing functions • Monitoring & Evaluation

Strengthening the capacity of Mo. H The Mo. H has sourced a consultant to assist with the following objectives: • Development of a performance measurement framework • Examination and assistance in improving the Anguilla Mo. H Quality Management program including staff training.

Strengthening the capacity of Mo. H • Integrate epidemiology to enhance the use of information and the effectiveness of policy making, program development, and assessment related to population health. • Evaluate and help improve the Ministry’s Health Planning functions.

Strengthening Health Systems National Health Fund: • It is proposed that a National Health Fund (NHF) is created to purchase health care for the whole population of Anguilla as clinically needed and in an equitable manner. • The NHF is based on a primary health care model

Pre-requisites for the Establishment of the NHF • The provision of the Health Services be removed from political interference • Establishment of the HAA • Quality of health services improved • Accreditation of the HAA by the Canadian Council on Health Services Accreditation • NHF management must be free from political interference • Establishment of the NHF Board and the recruitment of the NHF Director

National Health Fund The NHF has been based on the guiding principles of social health insurance which include: solidarity - pooling the financial risk for the whole population sustainability - creating an independent funding mechanism able to match revenue to needs

NHF equity - introducing a prospective payment system removing financial barriers to access efficiency - avoiding the fragmentation and high overheads of multiple funding sources effectiveness - developing technical purchasing capacity in the NHF accountability - including mechanisms transparency and consumer involvement.

NHF The Fund will be managed to ensure that money is spent on high-quality, value-formoney services, and not wasted on unnecessary treatment. Individuals will contribute to the Fund when they are economically active, but the Fund will pay for care for everyone as it is needed, including children and the retired

NHF It will be financed by a combination of: • Contributions from employers and employees based on income • An annual Go. A contribution from the Consolidated Fund (which may result in a new levy or levies on the consumption of selected items) • Any other sources as may be decided by Ex. Co from time to time.

Financing Options • Contributions of 5% of monthly income; 2. 5% from employers and 2. 5% from employees • an annual Go. A contribution from the Consolidated Fund which will include • • Monies used to pay for health coverage for Civil Servants Monies allocated to medical treatment overseas Monies currently paid to the Health Authority of Anguilla Any other sources as may be decided by Go. A Executive Council from time to time

Anguilla NHF Operations • The Fund will buy health care services from providers offering services to a standard acceptable to the Fund • It will be managed by a technical capacity able to negotiate quality and prices with providers.

Anguilla NHF Operations • Providers will include the HAA and approved private practitioners. • Selected overseas hospitals will provide specialist tertiary care that cannot be provided adequately on-island

Payment for Procedures • Primary care will be purchased by the Fund for consumers • Providers will be contracted (through an annual service agreement) based on the number of consumers registered with them, and not on a fee-per-item-ofservice reimbursement basis.

Anguilla NHF Operations • • Access to hospital and specialist care paid for by the Fund will be through referral by approved primary care providers only. Access to sub-specialist care overseas paid for by the Fund will be only through referral by approved secondary care providers – in practice, the HAA.

Anguilla NHF Operations • Overseas specialist care will be purchased on a fee-for-service basis but under pre-agreed unit rates. Charges, utilisation rates and the validity of treatment will be monitored by the Fund to maintain quality and value-for-money, and to stay within budget.

Patient Registration • Providers will be accredited to provide services under the NHF subject to the satisfaction of the Director of the NHF that services provided are of a sufficiently high standard

Patient Registration • Consumers will be required to register at one primary care provider within 3 months of registering with the NHF • They may do this at the start of the Fund’s operations or when they visit a provider for the first time.

Patient Registration • • All dependents and family members will register with the same provider and providers will be limited by a maximum list size in order to ensure quality of care The maximum list size will be decided by the Fund but is likely not to exceed 2, 000 persons to include NHF-funded and non-NHF patients.

Patient Registration • Providers are prohibited from excluding patients wishing to register with them until the maximum list size of patients has been reached.

Patient Registration • Patients may register with another provider under the following conditions: • the receiving provider has space on his/her register for the entire family • at least 30 days notice • changes cannot exceed more than 3 in a calendar year

Other Interventions to Strengthen Health Systems • Establishment of a Department of Health Protection including the appointment of a Chief Medical Officer, Surveillance Officer, and Epidemiologist • Updating of Environmental Health Legislation

Other Interventions to Strengthen Health Systems • Development of legislation to regulate health professionals • HAA surveillance officer identified and dedicated specifically to surveillance activities • Establishment of Directorate of Health Services Quality Management

Expansion of Mo. H Human Resources • • Approval of post for Surveillance Officer for the Ministry Establishment of a Health Planner post separate from planning in other social sectors Expansion of the Directorate of Health Services Quality Management Expansion of the National AIDS Programme

New Approaches to Health Systems Management • Annual Services Agreement in effect • Performance Appraisal Process implemented • Recognition and Reward programme established • Quarterly reviews in effect • Operational planning framework implemented • Full delegation of budget to managers

New Approaches to Health Systems Management • Board Committees established – Patient care, Nursing, Human Resources and Finance • Management Committees established – Quality and Audit, Health and Safety, Disaster Management and Information Management being implemented • Instrument of Communication (Mo. H/HAA)

Framework of Objectives to evaluate Health Sector Reform • Access • Equity • Quality • Effectiveness • Efficiency • Sustainability

Access 2003 2004 2007 Facilities with 0 a doctor (PHC) 2 3 Pharmacy 3 3 100% 1 Immunization 100% Coverage

Access • • • The reorganization and expansion of primary health care, more patients have access to core basic package of primary medical care The establishment of health districts and the availability of a health team comprised of family physicians and professional nursing staff, these centres now provide a more sustained and reliable package of services from 8. 00 a. m. to 4. 00 p. m. The result has been a decrease in the number of non-emergency cases in the A&E

Equity 2003 2004 2005 Spending on PHC 3, 145, 000 2, 960, 000 3, 445, 000 Spending on secondary Capital Investment 7, 200, 000 6, 050, 000 6. 820, 000 395, 000 375, 000 700, 000

EFFECTIVENESS 2003 2004 2005 Crude Birth 14. 1 Rate 14. 5 14. 3 Crude Death Rate 5. 6 5. 5 5. 4 In-patient deaths 32 23 23

Efficiency 2003 2004 2005 Bed 41% Occupancy 31% 21% Average 5 length of stay (days) % of 61% expenditure on personnel 4 3 79% 69%

Sustainability 2003 2004 2005 % of spending 100% from Government 77% 79% Current Ratio Working Capital NA 1. 6: 1 1. 7: 1 NA 582, 000 817, 000 Health spending to GDP 5. 4% 5. 3% 5. 4%

Client Satisfaction • 80% of patients view doctors as professional and caring • 78% of patients described the food as very good / good on taste, appearance and choice • 94% of patients viewed the physical environment as very good / good compared to 64% in 2004 • 95% of dental patients felt their needs were met • 85% of dental patients viewed staff as prompt and helpful in 2005 compared to 73% in 2004 Source: Health Information Department

“There is a need for change to ensure quality, efficiency, equity, cost containment, financial sustainability, and inter-sectoral collaboration. The outcome of this new dispensation of change seeks to give the people of Anguilla greater access to health services and empower individuals and communities to assume responsibility for their health. ” ---Source: Anguilla’s National Strategic Plan for Health